endocrinology

A 62-year-old woman presents to her GP with a 6-month history of increasing fatigue, generalised bone aches, and constipation. She has no significant past medical history and takes no regular medications. Physical examination is unremarkable. Initial laboratory investigations reveal a corrected serum calcium level of 3.1 mmol/L (reference range: 2.1-2.6 mmol/L) and an elevated parathyroid hormone (PTH) level of 180 pg/mL (reference range: 10-65 pg/mL). A 24-hour urine calcium excretion is 12 mmol/day (reference range: 2.5-7.5 mmol/day). She is referred for further imaging, the results of which are shown. Based on the available information, what is the MOST appropriate next step in the management of this patient?

A 52-year-old woman with a 10-year history of type 2 diabetes mellitus presents to your clinic for a routine follow-up. She has been experiencing difficulty in controlling her blood glucose levels despite being on metformin and glipizide. Her HbA1c is 8.5%. She has a BMI of 32 kg/m² and a sedentary lifestyle. She reports consuming a diet high in processed foods and sugary beverages. Her blood pressure is 140/85 mmHg, and her lipid profile shows elevated LDL cholesterol. Which of the following dietary and lifestyle modifications is most likely to improve her glycemic control and overall cardiovascular risk profile?

A 32-year-old woman presents to her GP with a 3-month history of fatigue, weight gain, and feeling cold all the time. She also reports constipation and dry skin. She has no significant past medical history and is not on any medications. On examination, her blood pressure is 120/80 mmHg, heart rate is 60 bpm, and she has a slightly enlarged thyroid gland. Laboratory tests reveal a low free T4 level and an elevated TSH level. Which of the following is the most appropriate initial treatment for this patient?

A 68-year-old male presents with a serum calcium of 2.8 mmol/L (2.1-2.6 mmol/L) and PTH of 95 pg/mL (10-65 pg/mL). He denies kidney stones but reports new-onset constipation. Relevant imaging is shown. What is the MOST likely diagnosis?

A 32-year-old woman, currently 28 weeks pregnant, presents to the antenatal clinic for a routine check-up. She has a history of gestational diabetes mellitus (GDM) diagnosed at 24 weeks of gestation. Her current treatment includes dietary modifications and regular blood glucose monitoring. Her recent fasting blood glucose levels have been consistently between 5.5 and 6.0 mmol/L, and her postprandial levels are between 7.5 and 8.0 mmol/L. She reports feeling well and has no symptoms of hypoglycemia. Her obstetric history includes one previous pregnancy complicated by GDM, which was managed with insulin. Her current pregnancy is otherwise uncomplicated. What is the most appropriate next step in the management of her gestational diabetes?

A 68-year-old woman presents with a 2-week history of progressive weakness in her right arm and leg, associated with a tremor in the right hand. She also reports feeling more tired than usual. Her general practitioner noted an elevated TSH (12 mIU/L, reference range 0.4-4.0 mIU/L) on routine blood tests done a month ago, but free T4 was within the normal range (15 pmol/L, reference range 10-20 pmol/L). On examination, she has mild right-sided hemiparesis (MRC grade 4/5) and a coarse tremor in the right hand, worse with action. Reflexes are brisk on the right. The rest of the neurological exam is unremarkable. She has mild bradycardia (55 bpm) but no other signs of overt hypothyroidism. What is the most appropriate initial investigation?

A 45-year-old woman presents to her general practitioner with a 3-month history of progressive fatigue, weight gain, and cold intolerance. She also reports constipation and dry skin. On examination, her blood pressure is 110/70 mmHg, heart rate is 60 bpm, and she has a delayed relaxation phase of her deep tendon reflexes. Laboratory tests reveal a low free T4 level and an elevated TSH level. Which of the following is the most appropriate initial management?

A 60-year-old woman presents to her GP with a 3-month history of fatigue, weight gain, and feeling cold all the time. She also reports constipation and dry skin. On examination, she has a slow heart rate and her skin appears dry and coarse. What is the most appropriate initial investigation?

A 55-year-old male presents to his GP complaining of bilateral breast tenderness and swelling over the past 6 months. He denies nipple discharge, weight changes, or other systemic symptoms. His vital signs are normal. He takes no regular medications. Considering the clinical presentation and the provided image, which of the following investigations is the most appropriate initial step in evaluating this patient?

A 45-year-old woman presents to the clinic with a 6-month history of fatigue, weight gain, and feeling cold all the time. She also reports hair loss and constipation. On examination, her skin is dry, and her reflexes are delayed. Her blood pressure is 110/70 mmHg, and her heart rate is 60 bpm. Laboratory tests reveal a low free T4 and elevated TSH. What is the most likely diagnosis?

A 62-year-old woman presents with fatigue, bone pain, and constipation. Laboratory tests reveal serum calcium 3.1 mmol/L, PTH 180 pg/mL, and elevated 24-hour urine calcium. Imaging studies are shown. Considering the clinical presentation and investigation findings, what is the MOST appropriate next step in the management of this patient?

A 62-year-old woman presents to her GP with a 6-month history of increasing fatigue, generalised bone aches, and constipation. She denies polyuria or polydipsia. Her past medical history is unremarkable, and she takes no regular medications. On examination, her vital signs are stable, and there are no palpable neck masses. Initial laboratory investigations show serum calcium 3.1 mmol/L (2.1-2.6), phosphate 0.7 mmol/L (0.8-1.4), PTH 180 pg/mL (10-65), and 24-hour urine calcium 450 mg (100-300). She is referred for further imaging, the results of which are shown. Based on the available information, what is the MOST appropriate next step in the management of this patient?

A 62-year-old woman with osteoporosis and a history of kidney stones presents with a serum calcium of 2.9 mmol/L (2.1-2.6 mmol/L) and PTH of 120 pg/mL (10-65 pg/mL). She denies neck pain or swelling. The provided imaging was obtained. What is the MOST appropriate next step?

A patient is on metformin 1g BD, with a blood pressure of 135/85 mmHg, HbA1c of 8.5%, no history of cardiovascular disease, fasting blood sugar of 9 mmol/L, and an albumin/creatinine ratio of 500. Which drug should be added to their treatment regimen?

A 58-year-old woman presents with persistent fatigue, muscle weakness, and vague abdominal pain. Investigations reveal serum calcium 3.2 mmol/L (2.1-2.6), PTH 190 pg/mL (10-65). Renal function is normal. She denies family history of endocrine disorders. Imaging studies are performed, as shown. Considering the clinical presentation and the findings from the imaging modalities, what is the definitive management strategy for this patient?

A 62-year-old woman presents to her general practitioner complaining of fatigue, bone pain, and constipation for the past several months. She denies any significant past medical history. Initial laboratory investigations reveal an elevated serum calcium level of 3.1 mmol/L (reference range: 2.1-2.6 mmol/L) and an elevated parathyroid hormone (PTH) level of 180 pg/mL (reference range: 10-65 pg/mL). A 24-hour urine calcium excretion is also elevated. The patient is referred for further imaging, the results of which are shown. Based on the available information, what is the MOST appropriate next step in the management of this patient?

A 62-year-old woman with osteoporosis and a history of kidney stones presents for evaluation. Her calcium is 2.9 mmol/L (2.1-2.6 mmol/L), PTH 110 pg/mL (10-65 pg/mL), and creatinine is normal. She denies neck pain or swelling. Given the imaging, what is the MOST appropriate next step?

A 28-year-old woman presents to the clinic with a 2-week history of polyuria, polydipsia, and weight loss. She has no significant past medical history. On examination, she appears dehydrated, and her blood pressure is 100/60 mmHg. Laboratory tests reveal a blood glucose level of 18 mmol/L and ketones in the urine. What is the most likely diagnosis?

A 62-year-old woman presents with fatigue, constipation, and bone pain. Serum calcium is elevated. The provided imaging was obtained. What is the MOST likely underlying cause of her presentation?

A 55-year-old man with a history of type 2 diabetes presents for a routine check-up. His last HbA1c level, measured three months ago, was 8.2%. He reports no new symptoms and is currently on metformin. What is the most appropriate next step in managing his diabetes?

A 58-year-old woman presents with persistent fatigue, muscle weakness, and vague abdominal pain. Her serum calcium is 3.2 mmol/L (2.1-2.6 mmol/L), and PTH is 190 pg/mL (10-65 pg/mL). Renal function is normal. She denies any family history of endocrine disorders. Imaging studies are performed, as shown. Based on the clinical context and the imaging findings presented, which of the following represents the definitive management strategy for this patient?

A 58-year-old male presents with concerns about breast enlargement over the past year. He denies pain or nipple discharge. He takes no medications and has no known medical conditions. Examination reveals the findings in the image. What is the MOST appropriate initial investigation?

A 58-year-old male presents with concerns about breast enlargement over the past year. He denies pain or nipple discharge. He takes no medications and reports no significant past medical history. Examination reveals the findings in the image. What is the MOST appropriate initial investigation?

A 62-year-old woman with osteoporosis and a history of kidney stones presents for evaluation. Her calcium is 2.9 mmol/L (2.1-2.6 mmol/L), and PTH is 110 pg/mL (10-65 pg/mL). Imaging is shown. What is the MOST appropriate next step?

A 45-year-old woman presents with fatigue, weight gain, and cold intolerance. On examination, she has dry skin and a delayed relaxation phase of deep tendon reflexes. Her TSH level is elevated, and free T4 is low. What is the most appropriate treatment for her condition?

A 62-year-old woman presents to her general practitioner complaining of fatigue, bone pain, and constipation for the past several months. She denies any significant past medical history. Her vital signs are stable. Initial laboratory investigations reveal an elevated serum calcium level of 3.1 mmol/L (reference range: 2.1-2.6 mmol/L) and an elevated parathyroid hormone (PTH) level of 180 pg/mL (reference range: 10-65 pg/mL). A 24-hour urine calcium excretion is also elevated. The patient is referred for further imaging, the results of which are shown. Based on the available information, what is the MOST appropriate next step in the management of this patient?

A 58-year-old man presents with concerns about breast enlargement over the past year. He denies pain or nipple discharge. He takes medication for hypertension. Examination reveals the findings in the image. Which of the following is the MOST appropriate initial investigation?

A 32-year-old woman presents to the clinic with a 6-month history of irregular menstrual cycles and excessive facial hair growth. She has gained 5 kg over the past year and reports difficulty losing weight despite regular exercise. On examination, she has acne and hirsutism. Her BMI is 28 kg/m². Blood tests reveal elevated testosterone levels and normal TSH and prolactin levels. What is the most likely diagnosis?

A 62-year-old woman with osteoporosis and a history of kidney stones presents for evaluation. Her calcium is 2.9 mmol/L (2.1-2.6 mmol/L), PTH 110 pg/mL (10-65 pg/mL), and creatinine is normal. She denies neck pain or swelling. Given the imaging, what is the MOST appropriate next step?

A 62-year-old woman with a 15-year history of type 2 diabetes mellitus presents to her general practitioner with complaints of worsening vision over the past six months. She also reports intermittent tingling and numbness in her feet, which has been progressively worsening. Her diabetes has been poorly controlled, with recent HbA1c levels consistently above 9%. She has a history of hypertension and hyperlipidemia, both of which are managed with medication. On examination, her blood pressure is 140/85 mmHg, and her BMI is 32 kg/m². Fundoscopic examination reveals microaneurysms and cotton wool spots. Urinalysis shows microalbuminuria. Which of the following interventions is most likely to address the underlying pathophysiological mechanism of her visual symptoms?

A 16-year-old boy is diagnosed with Type 1 diabetes mellitus after presenting with polyuria, polydipsia, and weight loss. His blood tests show elevated blood glucose levels and the presence of autoantibodies against pancreatic beta cells. In contrast, a 55-year-old woman is diagnosed with Type 2 diabetes mellitus, characterized by insulin resistance and obesity. Which of the following best describes the pathophysiological differences between Type 1 and Type 2 diabetes?

A 55-year-old man with a history of type 2 diabetes mellitus presents with polyuria, polydipsia, and fatigue. His blood tests reveal a fasting blood glucose level of 15 mmol/L and HbA1c of 9.5%. He is currently on metformin. What is the most appropriate next step in management?

A 58-year-old man presents with concerns about breast enlargement. Examination reveals the findings in the image. Which of the following is the MOST appropriate initial investigation?

A 58-year-old woman presents with persistent fatigue, muscle weakness, and vague abdominal pain. Her serum calcium is 3.2 mmol/L (2.1-2.6 mmol/L), and PTH is 190 pg/mL (10-65 pg/mL). She denies any history of fractures or kidney stones. She was referred for imaging, as shown. What is the MOST appropriate next step in managing this patient?

A 62-year-old man presents with bilateral breast enlargement, as shown. He denies pain or nipple discharge. What is the MOST likely underlying cause?

A 58-year-old woman presents with persistent fatigue, muscle weakness, and vague abdominal pain. Her serum calcium is 3.2 mmol/L (2.1-2.6 mmol/L), and PTH is 190 pg/mL (10-65 pg/mL). Renal function is normal. She denies any family history of endocrine disorders. Imaging studies are performed, as shown. What is the MOST appropriate next step in managing this patient?

A 55-year-old man with a 15-year history of type 2 diabetes presents with numbness and tingling in his feet. On examination, there is reduced sensation to light touch and vibration in a stocking distribution. What is the most appropriate initial management for his symptoms?

A 62-year-old woman with a 15-year history of type 2 diabetes mellitus presents to the emergency department with confusion, polyuria, and polydipsia over the past three days. She has been non-compliant with her medications and diet. On examination, she is lethargic and dehydrated, with a blood pressure of 100/60 mmHg, heart rate of 110 bpm, and respiratory rate of 20 breaths per minute. Laboratory tests reveal a blood glucose level of 38 mmol/L, serum sodium of 150 mmol/L, serum potassium of 4.0 mmol/L, serum bicarbonate of 22 mmol/L, and a serum osmolality of 340 mOsm/kg. Urinalysis shows no ketones. Which of the following is the most appropriate initial management step?

A 30-year-old woman presents to her GP with fatigue, weight gain, and cold intolerance over the past 6 months. She also reports constipation and dry skin. On examination, she has a slightly enlarged, non-tender thyroid gland. Her TSH level is elevated, and free T4 is low. What is the most appropriate treatment for this condition?

A 62-year-old woman presents with fatigue and bone pain. Serum calcium is elevated. The provided imaging was obtained. What is the MOST likely underlying cause of her hypercalcemia?

A 50-year-old woman presents to her GP with a 3-month history of fatigue, weight gain, and feeling cold all the time. She also reports constipation and dry skin. On examination, she has a slow heart rate and delayed relaxation of deep tendon reflexes. Her thyroid function tests show elevated TSH and low free T4 levels. What is the most appropriate treatment for her condition?

A 70-year-old man presents with a vertebral fracture after a minor fall. Reviewing risk factors for osteoporosis, which of the following is the most likely risk factor?

A 55-year-old man with type 2 diabetes mellitus presents for a routine follow-up. His HbA1c is 9.0% despite being on metformin 1000 mg twice daily. He has a BMI of 32 kg/m² and no history of cardiovascular disease. What is the most appropriate next step in his management?

A 62-year-old woman presents to her general practitioner complaining of fatigue, bone pain, and constipation for the past several months. She denies any significant past medical history and her vital signs are stable. Initial laboratory investigations reveal an elevated serum calcium level of 3.1 mmol/L (reference range: 2.1-2.6 mmol/L) and an elevated parathyroid hormone (PTH) level of 180 pg/mL (reference range: 10-65 pg/mL). A 24-hour urine calcium excretion is also elevated. The patient is referred for further imaging, the results of which are shown. Based on the available information, what is the MOST appropriate next step in the management of this patient?

A 58-year-old man with a 10-year history of Type 2 diabetes presents to the clinic for a routine follow-up. He is currently on metformin and lifestyle modifications, but his HbA1c has increased to 8.5% over the past six months. He reports adherence to his medication and diet but has a sedentary lifestyle. What is the most appropriate next step in managing his diabetes?

A 32-year-old woman presents to her general practitioner with a 2-month history of fatigue, weight gain, and feeling cold all the time. She also reports hair loss and constipation. On examination, her heart rate is 58 bpm, and she has dry skin and a delayed relaxation phase of the deep tendon reflexes. Her thyroid function tests reveal a high TSH level and low free T4. She has no significant past medical history and is not on any medications. Which of the following is the most appropriate initial management for her condition?

A 58-year-old man presents with concerns about breast enlargement over the past year. He denies pain or tenderness. He takes medication for hypertension. Examination reveals the findings in the image. Which of the following is the MOST appropriate initial investigation?

A 62-year-old woman presents to her general practitioner complaining of fatigue, bone pain, and constipation for the past several months. She denies any significant past medical history and is on no regular medications. Physical examination is unremarkable, and vital signs are within normal limits. Initial laboratory investigations reveal an elevated serum calcium level of 3.1 mmol/L (reference range: 2.1-2.6 mmol/L) and an elevated parathyroid hormone (PTH) level of 180 pg/mL (reference range: 10-65 pg/mL). A 24-hour urine calcium excretion is also elevated. The patient is referred for further imaging, the results of which are shown. Based on the available information, what is the MOST appropriate next step in the definitive management of this patient?

A 58-year-old male presents to his GP complaining of bilateral breast enlargement over the past year. He denies any pain or tenderness. He takes no medications and reports no significant past medical history. Examination reveals the findings in the image. What is the MOST appropriate initial investigation?

A 62-year-old woman presents to her general practitioner complaining of fatigue, bone pain, and constipation for the past several months. She denies any significant past medical history. Initial laboratory investigations reveal an elevated serum calcium level of 3.1 mmol/L (reference range: 2.1-2.6 mmol/L) and an elevated parathyroid hormone (PTH) level of 180 pg/mL (reference range: 10-65 pg/mL). A 24-hour urine calcium excretion is also elevated. The patient is referred for further imaging, the results of which are shown. Considering the clinical presentation and the findings from the imaging studies, which of the following surgical approaches is MOST likely to be indicated?